WI0500326_GEO THERMAL_20101221

Permit Number
Program Category
Ground Water
Permit Type
WI0500326 /
Injection Water Only GSHP Well System (5QW)
Primary Reviewer
michael. rogers
Coastal SW Rule
Permitted Flow
Facilit
Facility Name
C. Thomas Childrey SFR
Location Address
3507 Churchill Rd
Raleigh
Owner
Owner Name
C
Dates/Events
NC 27607
Thoma Childrey
s
Orig Issue
12/21/10
App Received Draft Initiated
11/24/10
Re ci ulated Activities
Hea t Pump Injection
Outfall .. ;,
Scheduled
Issuance
Central Files: APS_ SWP_
12/21/10
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Glen Adam Darch
13109 Bold Run Hill Rd
Wake Forest
Major/Minor
Minor
Region
Raleigh
County
Wake
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
C Thomas Childrey
3507 Churchill Rd
Raleigh
NC
NC
Public Notice Issue
12/21/10
Effective
12/21/10
27587
27607
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
AVA
~CDENR
North Carolina Department of Environment and Natural Resources
Divi sion of Wat er Quality
Beverly Eaves Perdue
Governor
C. Thom as Childrey
Maria N . C hii d rey
3 507 C hurchill Ro a d
Raleigh. N C 2 7607
Coleen H. Sullin s
Directo r
12/21/20 10
Subject Acknowledgement oflntent to Construct Type 5QW Injection Well System
Permit No. WI0500326
35 07 Churchill Rd . Raleigh, NC ?.76 07
Dear Mr. & Mrs. Childrey:
Dee Fre eman
Se cretar y
On 11/24/2010, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-onh:
geothermal injection well system for the operation of a ground-source heat pump located at the address referenced above. An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met:
1. The injection well system contains only potable water,
2. ' The injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title ISA Section 2C Subchapter .0213; and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Section 2C Subchapter .0211(u)(2). Additionally, you should contact the Wake County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] or Michael.Roeersrcimcdenr.gov if you have any questions.
Sincerely,
ro,Q.~A-~
cc: Raleigh Regional Office -APS
APS Central Files -Permit No. Wl0500326
Wake County Health Dept.
Glen A. Darch Well Drilling (Glen Darch)
Bov.'ln an Mec hanical Services, In c. (Steve Bow man)
AQUIFER PROTECTION SECTION
1636 Mail Service Cen ter, Raleigh , North Carolina 27699-1636
Location: 2728 Capital Boulevard, Raleigr,. North Carolina 27604
Super visor
Phone: [phone] I FAX 1: 919-715 -0588; FAX 2: 919-715-6048 I Customer Service: 1-877-623-6748
Internet www.ncw atergu alrty.org .
AJ1 Eq ual Opportu r.;~, \ Affi rma ::ve Ac:on Emp loyer
NOnehC .. ort . · aroun a
/vaturalf!/
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT A CLOSED -LOOP GEOTHERMAL
WATER -ONLY INJECTION WELL SYSTEM
TYPE SOW WELL(S)
in Accordance With the Provisions ofNCAC Title 1 5A 02C.0200
Print or tripe the required information and mail to address on the back page
DATE:
20 V I ° 003 '
Well Type Confirmation: Does the proposed system circulate potable water only (no additives) in
continuous piping that completely isolates the fluid from the environment (i.e.
closed -loop )?
Yes
x
Continue completing this form.
No Do Not complete this form. Complete other UIC application forms for installing
either a 5A7 well (open -loop well in g potable water into the aquifer) or a 5QM. well (closcd-
Ioop well containing additives such as R-22, ethanol, or other antifreeze or corrosion inhibitors).
A; PROPERTY OWNER(S)IAPPLICANT(S)
List each Property Owner listed on property deed (if owned by a business or government agency, stria
entity and a representative w/authority for signature): e . "'fl Qul A$ Cyr RI fe
(1) Mailing Address: 35 Cn CAL P ` lti Ut.. .
City: ikAALL4161 y ■ state; fir. zip Cam_ 2'14 ° 7 County_
HotneJQliiimiltle No.: SI ) s 7 ea . 07 7.-3 Cell No.:
Email Address: -Eck
Gjh 4 t � Website:
Pei R4., awe.
Physical Address of Well Site (if different than above):
City: State; Zip Code: - _ County: _
Home/Office Tele No.: Ce11 No.:
(2)
E. AUTHORIZED AGENT OF OWNER, IF ANY (if the Permit Applicant does not own the subject property,
attach a letter from the property owner authorizing Agent to install and operate UIC well)
Company Name:
Contact Person. EMAIL Address:
Address:
City: State: Zip Code: County:
Office Tele No.: Cell No.:
Website Address of Company, if any.
Crum! C 50'w Notification of Intrnt Form (Revised 812408) Page 1

C. WELL DRILLER INFORMATION
Company Name:Glen A Darch Well Dril ling
Well Driller Contractor's Name: Glen Darch
NC Contractor Certification No.: 3900A
Contact Person: Glen Dmdl EMAIL Address:gdwelldrilJ [e-mail]
Address: 13109 Bold Run Hill Road
City: Wake Forest Zip Code: 27587 County: Wake
Office Tele No.: [phone] Cell No.: [phone]
D. BL\T PUMP CONTRACTOR INFORMATION (if diffenat tllan driller)
Company Name:Bowman Mechanical Services Inc ·
B.
F.
G.
Contact Person: Steve Bowman EMAIL Address: bo-wman mechanical@.bellsouth.net
Address: 145 Technical Ct.
City: Gamer Zip Code: 27529 Counfy: Wake
Office Tele No.: [phone] Cell No.: (919) 427c..1425
STATUS OF APPLICANT ·
Private: X Federal: Commercial:
State: Municipal: __ Native American Lands:
INJECTION PROCEDURE (briefly describe how the injection well(s) will be used)
To o perate a heat pump for residential heating/coo ling/domestic water heater
WELL CONSTRUCTION DATA /
(I) Proposed date to be constructed: I I ~, l O Number ofl)orings: J
Approximate depth of each boring (feet):_~.......__· ___ _
2 Type of tubing to be used (copper. PVC. etc): RE 3408 polythylene
(3) Well casing. Is the well(s) cased? (check either (a.) Yes!!: (b'.) No below)
(a) Yes ___ . if yes. then provide casing information below
Type: __galvanized steel __ black steel__plastic __ other (specify)
Casing depth: From ___ to ___ feet. (reference to land surface)
Casing extends to above ground inches
(b) No X
( 4) Grout Info (material surrounding well casing and/or piping):
(a) Grout type: Neat Cement__ Beotonite X Other (specify)_
(b) Grout placement: Pumping_X Pressure__ Other __
(c) Grout depth of tubing (reference to land s1Jl"face): from .J~ to Q_
If well has casing, indicate grout depth: from ___ to __ (feet)
$ INJECTION -RELATED EQU1PMENf'
Attach a diagram showing the engineering layout or proposed modification of the injection equipment and exterior
piping/tubing associated with the injection operation. The manufacturer's brochure may provide supplementary
information.
L LOCATION OF WELL(S)
Attach two angrier of maps showing the following information:
(1) Include a Site Map (can be drawn) showing. buildings, property Imes, surface water bodies, potential
sources of groundwater contarninatinn and the orientation of and distances between the proposed well(s) and
any existing well(s) or waste disposal facilities such as septic tanks or drain fields located within 200 feet of
the geothermal heat pump well system, Label all features clearly and include a north arrow.
{2) The Site Map must show the subject property in relation to the surrounding area by using at least two fixed
refer points such as roads, streams, andlo highway inhxaections.
J. CERFIFICATION
Note: This Pernitt Appbeatkon must be meld by each pergola appearing en the
recorded legal property deeti..
"I hereby certify, under penalty of law, that T have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immedigtely responsible for obtaining said information, I believe that the information is true, accurate and complete.
I am aware that there are significant penalties, including the poesiibdity of Imes and imprisonment, for submitting
false information. I agree to construct, operates maintain, repair, and if applicable, abandon the injection well and
all related appurtenances m accordance with the apprav , • , .y .: aria • . •. • the Permit. -
Print or Type Full Name and tale
Signature of Property Own (Applicant
Print or Type Full Name and title
Signature of Authorized Agent, if any
Print or Type Full Name and title
Please return two copies of the completed Application package to:
North Carolina DEN'R-DWQ
Aquifer Protection Section-JAC Program
1.63611du Service Center
Raleigh, NC 27699-1636
Telephone [phone]
OPIJJUIC 5QW Na fi aatiun of latent Form (Revised 8/2008) Page 3

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